Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohort approach using propensity-score matching for both evaluation and targeting.

BACKGROUND: The high cost and undesirable consequences of polypharmacy are well-recognized problems among elderly long-term care (LTC) residents. Despite the implementation of the 1987 Omnibus Budget Reconciliation Act, which requires pharmacist review of drug regimens in this setting, medical and drug costs for LTC residents have continued to increase. OBJECTIVE: This study evaluates the North Carolina Long-Term Care Polypharmacy Initiative, a large-scale medication therapy management program (MTMP) that combined drug utilization review activities with drug regimen review techniques. METHODS: This was a prospective records-based study that used a difference-in-difference model with both historical and nonintervention group controls. To ensure equivalence among subjects, propensity scoring was used to match study subjects from participating LTC facilities with comparison subjects from nonparticipating facilities. Residents with interventions were grouped for analysis by intervention type-retrospective only, prospective only, or dual type (residents with both prospective and retrospective interventions)-and by intervention stage-review, recommendation, and drug change-plus an all-inclusive "all types" grouping that aggregated groups by intervention type, for a total of 10 total cohorts. RESULTS: In the overall population of 5255 study subjects identified, a US $21.63 per member per month drug-cost savings was observed. Although only 1 of 10 cohorts had a change in the number of drug fills, substantial reductions in 2 of 5 types of drug alerts were observed in all 10 cohorts. A reduction in the relative risk for hospitalization (0.84 [95% CI, 0.71-1.00]) was observed in the cohort of residents receiving a retrospective review. CONCLUSIONS: This Initiative suggests that an MTMP can be quickly launched in a large number of LTC facility residents to produce monetary drug-cost savings and improved health outcomes. Additionally, the evaluation of this program illustrates the utility of using propensity scoring techniques to target future intervention groups in a cost-effective manner.

Pharmacist response to alerts generated from Medicaid pharmacy claims in a long-term care setting: results from the North Carolina polypharmacy initiative.

OBJECTIVE: In response to burgeoning drug costs, North Carolina (NC) Medicaid encouraged pharmacists and prescribers to develop collaborative programs to reduce drug expenditures. One of these programs, the North Carolina Polypharmacy Initiative, was a focused drug therapy management intervention aimed at reducing polypharmacy in nursing homes. This intervention targeted patients with more than 18 prescription fills in 90 days, beginning in November 2002. These patients were believed to have a high likelihood of experiencing potential drug therapy problems (PDTPs). Consultant pharmacists were asked to utilize profiles displaying alerts generated from pharmacy claims to guide interventions in addition to usual-care drug regimen reviews. The pharmacists documented their reviews, recommendations, and resulting changes in drug therapy. Our objectives were to determine (1) the persistence of PDTP alerts following interventions by consultant pharmacists and (2) the impact of these interventions on patient drug costs from a payer perspective. METHODS: A before-after study with comparison group design was used. Medicaid prescription claims data were compared for the 90-day periods prior to the intervention (June-August 2002) and following the intervention (March-June 2003). The 90-day post-intervention period allowed for 2 to 3 follow-up prescriptions and reduced the drop-out rate. The 5 categories of potential problem alerts included potentially inappropriate medications (Beers criteria), substitution opportunity for a lower-cost drug, 16 drugs or drug classes with specific quality improvement opportunities (Clinical Initiatives list), therapeutic duplication, and length of drug therapy evaluation. RESULTS: A total of 253 nursing homes, involving 110 consultant pharmacists and 6,344 patients, were in the intervention arm, with 5,160 patients (81.3%) remaining at the end of the follow-up period. At baseline, study-group patients used an average of 9.7 prescriptions per month, costing the NC Medicaid program 517 US dollars per patient per month (PPPM). There were 6,360 recommendations offered for 3,400 patients, or an average of 1.87 recommendations per patient. Physicians concurred with 59.8% (3,801 of 6,360) of all recommendations to change drug therapy, about half involving a switch to a lower-cost drug. Two of 5 alert categories had significant (P <0.01) reductions in alert persistence: -10.8% for the study group versus -0.7% for the comparison group for the Clinical Initiatives list and -29.7% for the study group versus -14.1% in the comparison group for the drug substitution opportunity. Median drug costs per patient in the study group decreased by 12.14 US dollars (-0.92%), from 1,329.46 US dollars to 1,317.32 US dollars, and increased in the comparison group by 44.98 US dollars (3.35%), from 1,341.25 US dollars to 1,386.23 US dollars, creating a relative cost reduction of 57.12 US dollars per patient in the 3-month follow-up period, or 19.04 US dollars PPPM. CONCLUSION: A supplemental program of medication reviews for nursing home patients targeted by high drug utilization resulted in a reduction in the persistence of PDTP alerts and was cost beneficial based solely on drug cost savings. This intervention may be a model for future medication therapy management services provided by prescription drug plans under Medicare Part D for patients in long-term-care settings and possibly ambulatory patients.

A pharmacy management intervention for optimizing drug therapy for nursing home patients.

BACKGROUND: A drug therapy management service was designed to reduce polypharmacy among Medicaid recipients. This service selectively focused on patients who were high users of prescription drugs and had potential drug therapy problems (PDTPs). OBJECTIVES: This article reports the results of the first phase of the North Carolina Polypharmacy Initiative. The goals of this study were to determine: (1) the frequency with which recommendations were made by pharmacists in response to targeted profile alerts aimed at high-risk patients, (2) the frequency and type of drug therapy changes, and (3) the impact on drug-related quality and costs. METHODS: A before-after design was used. Nursing home patient profiles with PDTP alerts for specific drugs and drug categories were provided to consultant pharmacists. Targeted patients had received 218 prescription fills within 90 days. Pharmacists were compensated for performing and documenting targeted drug regimen reviews. Interventions of pharmacists and results after physician consultation are described, and cost impacts of changes in drug therapy are reported. Monetary results are shown in year-2002 U.S. dollars. RESULTS: Prescription profiles were generated from Medicaid claims data and sent to consultant pharmacists for 9208 patients in 253 nursing homes. Pharmacists returned 7548 (82%) of all profiles sent to them. After excluding 1204 patients (13%) who were discharged or deceased, 6344 patients (69%) remained for analysis. At baseline, patients used a mean (SD) of 9.52 prescriptions per month, costing the North Carolina Medicaid program a mean (SD) of 502.96 dollars (309.70). A mean of 1.58 recommendations were offered to prescribers. After physician consultation, > or =1 recommendation was implemented for 72% of patients with a change recommendation, 68% of whom experienced a switch to a lower-cost drug. Drug cost savings were a mean of 30.33 dollars/patient per month. Cost savings from 1 month alone covered the compensation paid to pharmacists for consultation efforts. CONCLUSIONS: This supplemental program of medication reviews for targeted nursing home patients resulted in a reduction of polypharmacy and was beneficial based solely on drug cost savings.